Wednesday, April 13, 2016

Ever since passage of the Affordable Care Act, a fierce debate has been waged over whether the law would work as advertised. While advocates promised that the design of new insurance markets would transform the way consumers buy health insurance, critics warned that the new market would never succeed. Reed Abelson and Margot Sanger-Katz have had front-row seats to the debate, and the two reporters took a few minutes to discuss when — and if — the market would stabilize.

Margot Sanger-Katz: Every time I write a story about the health law, I get comments and emails from people just above the income cutoff for subsidies. These are the people who have been most hurt by the health law. Plans on the exchanges are just really expensive for them, and o ften come with big deductibles, too. And if premiums keep rising, they'll keep getting squeezed. Analysts from the Urban Institute have done the math and found that some of them are paying more than 25 percent of their income on health care now. Still, it is awfully hard to imagine Congress approving massive new spending to make Obamacare more generous. Hillary Clinton has some proposals about affordability, but they don't include expanding subsidies.

Reed Abelson: One of the strengths of the law, and its main weakness, is its emphasis on keeping the status quo. While President Obama may have overpromised when he said you can keep your plan if you like it, the insurance isn't radically different. The only way companies can seem to bring down prices is by narrowing networks of hospitals and doctors or hiking deductibles. While Bernie Sanders seems to be offering the most dramatic change by proposing that everyone switch to a government plan like Medicare, I'm still looking for a market response — some real change in how care is delivered that is much less expensive or at least more effective.

Margot Sanger-Katz: This is the thing I say whenever anyone asks me what I think about the health law. It basically baked in all of the complexity and dysfunction of the pre-existing American health care system.

Reed Abelson: We're heading into the season when insurers and state regulators start talking about next year. Any thoughts on what we might expect?

Margot Sanger-Katz: I'm expecting them to ask for rate increases! The insurance companies are doing everything they can to broadcast their intentions to charge more. There are reasons we should expect the plans to do so even if the markets were already stable. Some of the early training-wheel programs set up by the law expire, which means the plans have to pay out more claims for really expensive patients.

Six years after the Affordable Care Act was signed into law we hear opinions ranging from what a phenomenal success it has been to what a miserable disaster it is. This brief excerpt from a discussion between two respected journalists who have followed the process closely, and who are well versed on the policy issues, provides us with a perspective on where we actually are on reform.

It is somewhat sobering. There have been some trade-offs such as expanding nominally the numbers insured but with insurance products that further limit provider choice and shift more costs to the patients. Margot Sanger-Katz says that the health law "basically baked in all of the complexity and dysfunction of the pre-existing American health care system."

Most of the system has remained about the same while the deficiencies introduced offset much of the gains. We are still left with tens of millions uninsured, tens of millions more who are underinsured, and costs that continue to increase in spite of the expansion of blunt financial barriers to beneficial health care services. Even employer-sponsored plans are beginning to deteriorate, especially because of higher deductibles and narrower networks.

Reed Abelson says that he is looking for "a market response — some real change in how care is delivered that is much less expensive or at least more effective." Yet it has been confirmed over the last half century that markets do not work in controlling health care spending. Nothing in the Affordable Care Act will change that in spite of wishes that feeble policy measures such as ACA exchange competition, ACOs, shared shavings, bundling, wellness programs, meaningless rhetoric of quality over quantity, and other ACA concepts would revolutionize health care. The revolution is not happening.

So claims of phenomenal success or miserable disaster can be ignored since we really have not fundamentally changed the infrastructure of our system. But with that background, we actually have failed: We failed to enact an Improved Medicare for All which would have met our goals for reform. We can still do it, you know.